Adolescence is a stage of rapid development during which human beings acquire new capacities and are faced with many new situations. It is a period when specific health concerns and issues emerge, and hence at this stage the risk of ill health increases ( 1 ). Of all challenges facing adolescents, those associated with sexual maturation are the most distinctive as well as the most problematic ( 2 , 3 ). In female adolescents, the main sign of sexual maturation is menstruation. Menstruation, is defined as the discharge of blood, secretions, and tissue debris from the uterus that recurs in non-pregnant breeding-age primate females at approximately monthly intervals and that is considered to represent a readjustment of the uterus to the non-pregnant state following proliferative changes accompanying the preceding ovulation ( 3 ).

The definition of illness or a problem depends primarily on the perception and statement of the subjects ( 4 ). Perception is inescapably an antecedent to behaviour. One acts not in response to an objective interpretation of events or language but, rather, in accordance to one’s perceptions, surrounding events or language ( 5 ). A study by Adinma and Adinma gives a range of perceptions about menstruation from being a physiological process to being an assurance of fertility. Other perceptions include: release of ‘bad blood’, cleansing of the womb, and washing off of an undeveloped baby ( 6 ). Drakshayani and Venkata in an Indian study, Agyekum in a Ghanian study, and Koff and Rierdan in an American study, have noted that some even perceive events like menstrual bleeding to emanate from the abdomen, intestines, and kidneys, or occurring as a consequence of curse from god, sin, and disease ( 7 – 9 ). The major reason behind such misconceptions is lack of education and awareness as well as personal and social inhibitions in discussing such matters especially in rural areas ( 10 ).

Furthermore, it is not an uncommon experience for girls to attain menarche without knowing about menstruation ( 23 ). Fatusi and Hindin in a sub-sahara African contextual study, Pswarayi in a Zimbabwean study, Gupta and Nutan in an Indian study, Turker, and Whisnant et al in America all agree that there are several misconceptions and traditional beliefs regarding menstruation, and that practices during menstruation are mostly unsafe and unhygienic ( 11 – 15 ). Issues of psychological or emotional changes and the real significance of the event are lacking, probably as a result of parents’ carefulness to avoid the introduction of the subject of sex ( 13 , 16 ); yet many adolescent and pre-adolescent girls have been reported by some studies to be sexually active ( 15 , 17 , 18 ).

Osujih in a Nigerian study, and Dilorio et al and Turker have expressed that there is a great need to prepare girls adequately for menstruation, else they will be led to look for information from sources which may be unreliable ( 14 , 19 ). The specific objective of this study is to examine how menstruation is perceived among adolescent secondary school girls in urban and rural LGAs of Akwa Ibom State, South-South, Nigeria.

This study is a comparative interventional study design conducted among adolescent secondary school girls in some select rural and urban areas of Akwa Ibom State South-Southern, Nigeria, the State lying between latitudes 4̊ 32̍ and 5̊ 53̍ North, and longitudes 7̊ 25̍ and 8̊ 25̍ East ( 24 ). The population of this study comprised 431,393 adolescent female in Akwa Ibom State. A minimum sample size of 546 was calculated and to allow for attrition, the total sample was rounded up to 600, and 150 female adolescents were selected from each of the 4 locations. Sample of 150 subjects were selected from two rural and two urban communities in the study area by multi stage random sampling. The first stage involved the stratification of local government areas into rural and urban (seven out of the thirty one local government areas in Akwa Ibom State are classified as urban, the other twenty four are rural) ( 25 ).

Two local government areas were selected from each stratum using the simple random sampling technique, by use of table of random numbers. In the second stage, among the thirty eight secondary schools (co-educational and girls’) that were listed in the four local government areas, one school each was selected per local government area (total of 4) using the simple random sampling technique, by use of table of random numbers. In the third stage, each school was stratified into lower (31) and upper (42) senior secondary classes to represent junior and senior adolescents. Selection of the classes was by stratified and then simple random sampling, using the table of random numbers, within each strata. The fourth stage involved selection of eligible students (2,867) that met the inclusion criteria (in-school girls aged between 10-19 years who had attained menarche) distributed over the selected streams of each class by the simple random sampling technique by use of table of random numbers.

In the use of table of random numbers, every list was itemized. Six hundred adolescent girls were recruited for the study Data collection was carried out at the school site during school hours, during the break period, with permissioon from the respective school principals. Pre-tested self-administered questionnaires, following an anonymous respondent approach were shared to the selected students who gathered at the assembly hall without the presence of teachers and male students. The questionnaire sought for information about demographic variables and perception of menstrual problems. The administration of the questionnaire was facilitated through the help of three female registrars. The intervention was by Information, Education and Communication (IEC) in which teaching and learning were approached through creative and involving methods. The researcher appropriately educated the girls on what normal menstruation is, in adolescents.

Data generated from this study was entered into the Statistical Package for Social Sciences (SPSS version 20). Percentages were used to analyse qualitative variables (where they did not add up to 100%, the responses were mutiple, and where they did not add up to the required percentage, there were no responses). Chi-square test was used to determine association between selected socio-demographic variables and their perception towards menstruation. Odds ratios and 95% confidence interval were estimated. Of the total 600 copies of the questionnaire administered, 559(93.2%), 286 from urban and 273 from rural were retrieved.

Table-1 displays the socio-demographic variables of adolescent girls in the urban and rural areas. Result shows that respondents from urban were younger (mean age 14.9 years) than those from rural (mean age 15 years), though the observed difference in their mean age was not statistically significant (t =1.2; p=0.232, p>0.05). In both groups majority of respondents were aged between 10-15 years. They were almost equally shared between SS1 and SS2 classes, and the majority of the subjects were of the Christian faith. Also, the fathers of subjects from urban areas were mostly public servants (54.2%), whereas they were mostly (54.3%) of the business class (especially trading in local wares e.g. food items, clothes etc.) in the rural areas. In the urban areas, 50% of fathers as compared with 23.5% in the rural areas had a tertiary education. Only a few of respondents fathers, 1%, were illiterates in the urban areas and 3.7% for rural.

Table-2 displays the perception of menstrual issues (menstrual knowledge) among adolescent girls in the rural and urban areas. For the rural respondents, 57.1% and 31.9% had little and no knowledge, respectively. About the function of menstruation at the inception of menarche, whereas in the urban areas, 61.9% and 16.8% of the respondents had little and no knowledge, respectively, about the function of menstruation at the inception of menarche; the observed difference between both group of girls was statistically significant pre-intervention (17.858; p<0.001) and post-intervention (22.861; p<0.001). The suggested age range for menarche was 9-20 years, with a mean of 12.6 years in the rural areas but it was 8-18 years, with a mean of 11.8 years in the urban areas. The observed difference was also statistically significant pre and post-intervention (48.373; p<0.001 and 46.667; p<0.001 respectively).

menstruation was a normal process with 10.6% feeling it was abnormal and only 4.0% felt it was a curse unlike in the urban areas where 98.3% of respondents felt menstruation was a normal process with 1% feeling it was abnormal, and only 0.7% felt it was a curse. Here again, the observed difference was statistically significant pre and post-intervention (31.353; p<0.001 and 33.303; p<0.001, respectively). Among rural respondents, 65.2% felt that menstruation was important for reproductive development, 22.7% for physical development while 12.1% felt it was unnecessary, and among urban respondents 83.5% of the girls felt menstruation was important for reproductive development, 13.3% for physical development while 2.8% felt it was unnecessary and 0.4% felt it was a sign that one had not conceived. The observed difference was again statistically significant pre and post-intervention 48.373 and 30.414; p<0.001 and 48.373; 23.243; p<0.001, respectively.

Table-3 shows the perception of menstrual issues ( menstrual attitude ) among adolescent girls in the rural and urban areas. On the need to stay away from people during menstruation, 56.4% and 71% of the girls in the rural and urban areas respectively concurred; the observed difference was statistically significant between the rural and urban respondents pre and post intervention ( χ( 2 )= 42.351; p<0.0001 and =14.889; χ( 2 )p<0.0001, respectively).

44.7% and 55.5% of rural and urban respondents, respectively, felt they were normal (should normally occur with menstruation) and the observed differences pre and post intervention were statistically significant (χ( 2 )=9.311; p=0.01, p<0.05) and (( 2 )=10.109; p=0.006, χ p<0.01) respectively; 48% rural respondents and 36.7% urban respondents felt some form of treatment was needed, the observed difference was statistically significant pre-intervention ( χ( 2 )=7.403; p=0.025), but not statistically significant post intervention ( χ( 2 )=5.622; p=0.06, p>0.05); however, 24.9% and 27.6% of rural and urban respondents, respectively, did not see the need for any treatment.

Various reasons were given on the need for treatment of menstrual problems: 19% and 16.8% of rural and urban respondents respectively, felt treatment was needed for pain relief; 4.8% rural respondents and 7.7% urban respondents felt it was to prevent problems like depression; 6.2% and 6.3% rural and urban respondents, respectively, felt it gave peace of mind. Though the observed difference was not statistically significant pre-intervention ( χ( 2 )=6.407; p=0.093, p>0.05), it was statistically significant post intervention ( χ( 2 )=10.274; p=0.016, p<0.05). Table-4 displays the perception of menstrual issues ( menstrual problems that require treatment ) among subjects. More than one-third of all respondents felt that severe menstrual pain needed treatment, and more than two-fifths of all respondents felt that heavy bleeding and weakness needed some treatment. The observed difference was statistically significant pre (χ( 2 )=13.381; p=0.001, p<0.001 and χ( 2 )=12.723; p=0.002, p<0.001, respectively) and post intervention (χ( 2 )=15.652; p<0.0001, p<0.001 and χ( 2 )=11.734; p=0.003, p<0.01, respectively).

This work explored the perception of menstruation among adolescent girls in some select rural and urban areas in Akwa Ibom, South-South Nigeria with respect to their locales with the aims of informing the design and delivery of health interventions in this part of the country. This study has shown that 4% of the rural girls and 0.7% of the urban girls perceived menstruation to be a curse unlike the 18.5% in a study in India ( 7 ), and nil in a study in Anambra ( 6 ). In an Indian comparative study, 9% urban respondents and 26 % rural respondents perceived menstruation to be a curse ( 10 ).

Majority of respondents in both settings of this study, 98.3% urban and 85.3% rural adolescent, perceived menstruation to be a normal process, this is in line with the majority of girls’ perception in an Indian study which recorded 66.15% ( 10 ). Also, majority of the respondents in this study (65.2% rural and 83.5% urban) felt it was for reproductive development. The observed rural-urban differences pre and post intervention were statistically significant; both groups had marginal increases in perception with regards to the importance of menstruation. This shows a fair knowledge of the significance of menstruation among respondents in contradict findings of 39.3% who perceived menstruation to be a physiological process in an Anambra study ( 3 ). Moreover, more urban respondents (71%) than rural respondents (48%) felt they should stay away from people during menstruation; this conforms to the pattern noted in two Indian studies where more than 50% of respondents were restricted from various domestic and social activities. Hence the existence of cultural taboos cannot be ruled out in our environments ( 7 , 20 ).

Also, about half of the rural and urban respondents felt that associated menstruation problems were normal, but about two-fifths of rural and urban respondents felt there was a need to treat these associated problems. This is in tandem with the findings in the study by Khanna et al where these problems were seen as necessary ( 21 ).

This Observed rural-urban difference that was statistically significant pre-intervention became statistically insignificant post intervention, showing an appreciable improvement in knowledge that treatment was needed for such problems. The first issue that needs to be addressed is adolescents’ knowledge about the physiology of menstruation, and then the right perceptions and practices. Cultural practices have crept into this modern day and age in terms of various forms of restriction from domestic and social activities during menstruation. O’ Connell et al had stressed on cultural practices and perception as determinants for health seeking behaviour ( 22 ).